380 Septic Application Soil & Perc Test 1998 FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
, Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.4004/& 15.405
Facility/system owner: Name:247„. ddress. 381! C44-et- �-r�
Address of facility 3 gOJ
Type of facility: residential institutional _ commercial _ school _
design flow per 310 CMR 15 203 gpd
�7
/ d-t
System designer: Name l/%1 6/NN'S Address 70 Ale Vt.-lacrit n- Phone No.
Local Upgrade Approval granted for
reduction in setbact(s) (specify)
pert rate of 30-60 min./inch (specify rate)
reduction in SAS area of up to 25%
(specify % reduction&size of SAS)
reduction in separation between
SAS&high groundwater
(specify reduction&perc rate)
relocation of a well (explain)
acat, lei 161 sy
List local variances granted (no DEP approval required per 310 CMR 15.412(4))
List variances granted requiring DEP approval
Board of th Approval of p red upgrade r T JVft i�IEe•--� He,xa r'Yefa
& Tide V
Si / , ;�ry
Si City/town D
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY
&BEFORE COMMENCEMENT OF CONSTRUCTION.
UV APPROVED PORN-12/01105
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPRO`,'Al,
PAGE 4 OF 5
8) Notice to Abutters
No application for upgrade approval in which the setback from property lines or a
private water supply well is reduced shall be complete until the applicant has
notified all abutters whose property or well is affected by certified mail at least ten
days before the Board of Health meeting at which the upgrade approval will be on
the agenda. Such notice shall include the date, time and place where the upgrade
approval will be discussed.
If the Department is the approving authority, then such notice to abutters must be
completed prior to the date of submission of the application to the Department.
The notices to abutters shall include a copy of the completed application form and
shall reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters:
Abutter Name Date notified
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Address
9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each
section must be completed):
a) . an upgraded system in full compliance with 310 CMR 15.000 is not feasible:
fiv0✓6/1 /C60/1/1 OA) tL7 Th »%eLT /06 cT&9CC
Ed v,.z{yrm-�
b) an alternative system moved pursuant to 310 CMR 15 283-15 288 is not feasible:
5t7k MTheg Sys%t✓1 is uaT fvcupa �
De o APPRONtD FORM-1147 IS
FORM 9A - APPLICATION FOR LOCAL UPGRADE PAPFFROV.t.
gl Notice to Abutters
No application for upgrade approval in which the setback from property lines or a
private water supply well is reduced shall be complete until the applicant has
notified all abutters whose property or well is affected by certified mail at least ten
days before the Board of Health meeting at which the upgrade approval will be on
the agenda. Such notice shall include the date, time and place where the upgrade
approval will be discussed.
If the Department is the approving authority, then such notice to abutters must be
completed prior to the date of submission of the application to the Department.
The notices to abutters shall include a copy of the completed application form and
shall reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters:
Date notified
Abutter Name
Address
Date notified
Abutter Name
Address
Date notified
Abutter Name
Address
Date notified
Abutter Name
Address
9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each
section must be completed):
a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible:
m T /cat; 'SEA8riC/
pE4v,P.‘Ma.--).,,-'
b) an alternative system ajproved pursuant to 310 CMR 15.283-15.288 is not feasible:
et-TE??r/P,T!t'` 5ys(cAA 15 / Q% C:Opc3 ".:
DEP APPRO■W FORM-11/0115
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 OF 5
NIFt Up to 25% reduction in subsurface disposal area design requirements (state required
& proposed size)
Relocation of water supply well (identify well, describe relocation)
°air' Reduction of required separation between bottom of SAS & high groundwater
(specify proposed reduction & pert rate)
Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the
Code)
Sec- C
%ioN 6 ([0
System upgrades that cannot be performed in accordance with 310 CMR 15.404 &
15.405, or in full compliance with the requirements of 310 CMR 15.000, require a
variance pursuant to 310 CMR 15.410-15.417.
7) If the proposed upgrade involves a reduction in the required separation between the bottom
of the soil absorption system and the high groundwater elevation, an Approved Soil
Evaluator must determine the high ground water elevation pursuant to 310 CMR
15.405(l)6)(1). The evaluator must be a member or agent of the local approving authority:
Distance from soil absorption system to high groundwater
feet
As determined by:
Evaluator's name
Evaluator's signature
Date of evaluation
DPP APPROVED FORM• II`O795
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROV,SJ
PAGE ? OF ;
4) Type of existing system
privy cesspool(s) / conventional system
Other (describe)
Type of soil absorption system ([retches, chambers, pits,etc.)
Le�cklimcz, rr
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system _ gpd ° UNKNDW•"'J
Approved? yes approval date
no why?
b) Design flow of proposed upgraded system 1/455 gpd
a) Design flow of facility WO gpd
6) Proposed upgrade of existing system is
a) Voluntary
Required by order, letter, etc. (attach copy)
✓ Required following inspection required by 310 CMR 15.301 (provide date
inspection form was submitted to the approving authority) (date)
b) Describe the proposed upgrade to the system
RLPCAC& F',lL)N(X cjB6oe
RCg OISpose (
c) Which of the following are applicable to the proposed upgrade?
/ Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
RRDUcr //nw,nte /CO l567$»J!!4 °($ e £X/ N6 G c
n RR000SNb 545 S6cAo csT 7S ' 5(TSi3G,C
,n(/A Percolation rate of 30-60 minutes per inch (state actual pert rate)
DFP APPROVED FORM• 12 0'95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAiy ,
PAGE'/ OF
4) Type of existing system /
privy cesspool(s) ✓ conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pits,etc.)
LcmcHIAry p1r
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system gpd _ UPvKNDw'•)
Approved? yes approval date
no why?
b) Design flow of proposed upgraded system 415 gpd
c) Design flow of facility ¥1° gpd
6) Proposed upgrade of existing system is
a) Voluntary
Required by order, letter, etc. (attach copy)
/ Required following inspection required by 310 CMR 15.301 (provide date
inspection form was submitted to the approving authority) (date)
b) Describe the proposed upgrade to the system
RLCLrii c R/33ILJN(x .6OJ6`_•URRr'g 5& u4 6c OrSf(34c
rif
c) Which of the following are applicable to the proposed upgrade?
✓ Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
TD PRe c)6. £ 45, fCEA: c- mil Ps' 5t,77734C,f
N/A Percolation rate of 30-60 minutes per inch (state actual pert rate)
DEP APPROVED FORM. II 07 95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF 5
Commonwealth of Massachusetts
A/(AMA mibN , Massachusetts
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or
nonconforming system with a design flow of < 10,000 gpd, where full compliance, as defined in
310 CMR 15.404(1), is not feasible.
To be submitted to DEP: For the upgrade of a failed or nonconforming system with a design flow
of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full
compliance, as defined in 310 CMR 15.404(1), is not feasible.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the
addition of new design flow to a cesspool or privy or the addition of new design flow above the
existing approved capacity of a system constricted in accordance with either the 1978 Code or 310
CMR 15.000.
1) Facility/system owner
Name (303TR/ct7: at k,NScN
Address ?go el 714 EL
Phone # (4/3) SfS— 94 177
Address of facility g0 C/1 5Th-gf% -C !24 9p
2) Applicant (if different from above)
Name
Address
Phone #
3) Type of facility
/ residential commercial school
institutional
(Specify)
DEP APPROVED FORM 1E0-95
AS 13UILT -1);- ,> rJ (sty c MM nlico iz/s/Rm)
42, \ i<ar it -`. ;' (tog, PW-cm chNhL lrycc)
NI <;:z2 ANvri ,I'n 'k
Vi EN'f— — 314 " - 1 1/2 " DOUBLE WASHED STONE
\ 7 GARAGE
106 50 / � 60 LF -4" PVC PERF PIPE (5=.005)
"( // _
I „t
III ! I � I,—. 9 �'
t 4" SOLD PIPE ( ti c )
N9 l � � � o
z
n ,j 8 _ x
I
_---__--_= [--SEPTIC TANK \\
e OF - DISTRIBUTION BOX \
a ,> N �—
4 1
I 4" PVC SOLID PIPE - Sch 35 (S = .02 )
. i/toy - ,7 __
3`0 cLL J.nu t�
PERCOLATION TEST(S)
Time:
Time:
Observation Hole
#1
Observation Hole
#2
Depth of rem
K Li ti
Depth of Perc
Start Pre=soak
/6 f
Start Pre-soak
End Pre-soak
C
End Pre-soak
Time at 12"
Time at 12"
Time at 9°
49 5
Time at 9'
Time at 6"
/ 3 ',L7 l
Time at 6"
Time(9'-6')
1/219/3-
Time(9'-6')
Rate Min./Inch
) - J
Rate Min./Inch
'minimum of 1 percolation test must be performed in both the primary area AND reserve area.
Performed by
/ jaTt�7
.i rformed by
Witnessed by
Witnessed by
Comments:
TM# x r tnai *-',=L-tilf':;� 3`() C%[ c 4 i c / , i cY
�. . . . I I0 /,)-
PERCOLATION TESTIS)
Time: Time:
Observation Hole #1 Observation Hole #2
Depth of Pew Depth of Perc
Start Presoak //) r - Start Pre-soak
/✓ I! -�
End Pre-soak -� End Pre-soak
j(j
Time at 12" Time at 12"
Time at 9° i Time at 9°
/0 55
Time at 6" _ Time at 6"
Time(9°-6") /; Time(9"-6")
S
Rate Min/Inch Rate Min./Inch
"minimum of 1 percolation test must be performed in both the primary area AND reserve area.
Performed by //;j^a�1 ,y rtormed by
Witnessed by Wtnessed by
Comments:
•
- I
, ti
c -A
On-Site Review
LocationAddress or Lot#
Date
3C/Q -
�''f�`°
Owner
Q �r< ...AJ-Th.
Address
3 ,� ci
Fig
l0r f
`e
,
L Time
i �o c�,�
Weather
��� /0—ea-14-
Engineering Firm
Identity on Site Plan
D
Engineer or Sanitarian
f C
haet,A„ _ _
Land Use
A P-.- r Slope% Surface Stones
Vegetation.,/)
Landform
e
Position on Landscape
Distances from:
_ ._.. Y.
Open Water Body
Ge-/
feet
feet
Drinking Water Well
Drainage Way
1060,i-
tut) '
feet
feet
Property Line
Other
. ) 0 - 1-
i feet
feet
Possible Wet Area
Ai i
Deep Hole #: I
DEEP OBSERVATION HOLE LOG*
'MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Deo , orn - Soil Ramon
aura aches' _n
2.---I 4
- / - mss/
9
Soil Textwe
:USDA
Soil Color
tr •I i
// ��
Sod Mottling T
2s '"�
3
c
Other
!St' Stones Boulders C _
i5" / . .
✓-s
_ ,r _ Ail
`e
,
Parent Material(geologic) I V-C C-A Sei j f,(;�LJ
Depth to Bedrock
iG
Depth to groundwater. Standing Water in tae Hole
f C
Weeping from PO Face /1_,,,/Czi l rA.'
Estimated Seasonal High Ground Water
S .
Deep Hole it 0_1
DEEP OBSERVATION HOLE LOG*
MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Sort lonzon Sod Texlum
(USBA
A 5�
(
Sod Color
;Mansell'
Soil M otW ng
Other
(Structure, Stories Boulders Consistency
'arent Material(geologic) tyat /-" is-/
Depth to groundwater Standing ster in the Hole zinac r •
Estimated Seasonal High Ground Water
Depth to Bedrock
Weeping from Pa Face I
FORM 11 - SOIL EVALUATOR FORA
Page 3 of
Location Address or Lot No. 35f (,ME i e"?ft7,9 YZQ
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole..
❑ Depth weeping from side of observation hole Depth to soil mottlesga",VD 'inches
❑ Ground water adjustment feet
Index Well Number Reading Date .. Index well level
Adjustment factor Adjusted ground water level
inches
inches
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring
observed throughout the area proposed for the
If not, what is the depth of naturally occurring
Certification
rtify that on (date) I have passed the soil evaluator examination
approved by the Depa m nt of Environmental Protection and that the above analysis
was performed by m cons tent with . eq red training, expertise and experience
described in 310 CMR 1 ..017.
pervious material exist in all areas
soil absorption system?yS
pervious material?
OEP APPROVED FORM•12/01/95
Date /d -�7
Location Address or Lot No.
FORM 11 - SOIL EVALUATOR FOR/,
Page 3 of
Determination or Seasonal Hi;h Water Table
Method Used:
❑❑ Depth observed standing in observation hole
"0 Depth weeping from side of observation hole . . , inches
Depth to soil mottlesSd"5Ya 'i inches
0 nches
Ground water adjustment
feet
Index Well Number
.. .....
Adjustment factor .
Reading Date Index well level
Adjusted ground water level
Depth of Naturally Occurrin Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?VA
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on (date) 1 have passed the soil evaluator examination
approved by the Depa m nt of Environmental Protection and that the above analysis
was performed by m cons' tent with
described in 310 CMR 1 77 eq, red training, expertise and experience
-.0 .
DEP APPROVED FORA(. 12/07'95
Date
Location Address or Lot No.
FORM 12 - PERCOLATION TEST
`jf c-14/ 77--Fe-Ft-i-5,..0
COMMONWEALTH OF MASSACHUSETTS
�)pq rkkerript,A/Massachusetts
Percolation Tests
Date: _(D • Z- 7 Time:.
Observation Hole
Depth of Perc
Start Pre-soak
End Pre-soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate Min./Inch
to.` IS
to; 33
o: 33
10 ` gS
eO
as
MIS
INNS
l�� L
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed is, Site Failed ❑
PP*
Performed By:
Witnessed By:
Comments: ......
DEP APPROVED PORM-12107195
--._ 3 rVVQ d4'09 3'sv-
ff dJ-
bra~
L.,
,orr y
C
IL i
rd
G311.0901 ,341 01 taO {i
n4.,N
1113(1
u<ov¢38 b
ni-PvQ (Z4%' , 3,dyb45 &(I5
7I d ,L 3
br r 1
b �
or5. c
rdl
]3M SZ.I.3k RAIN �Ly �
1139)
1nOVC38
FORM I t - SOLL EVALUATOR FORM
Page 2
On-site Review
Deep Hale Number .. Date: it- ?'S7
Time: C.0...0,94-•• Weather 5✓"NY.
Location (identify on site plan) .
Land Use (<<' 5 ,Dati n L Slope (%1 ..,� Surface Stones ._..NDe"___ ........................... _._...._..
Vegetation :2-Rat r--1
_..
Landform .._ T 4aq C4
Hositinn on landscape (sketch on ti:o
Dutcr.ces from: / '
Open Water Body )BOO feet
Possible Wet Area a00 feet
Drinking Water Wef e-k—' 'feet
Ural:lag_ way. LP?... feet
Property Line 9t!jf feet
Other . .. _.
LP OBSERVATION hIOLE LOG
Deom from Surface
coshed
le
0 to
-To
/e
a� To 98'
1(
C
Sall Texture_
(USDA)
Sall Calm
(Munse9
Soil Matins Other
(S;ruc:ure. Stones. Boulders.
Corsistescv. % Greve°
F
1)
too (•94a.4 t Lo4'i
Nb
ay", 41"
Li o"
/=tic**re Ft n.0
to34/c5 *e 4 `c
✓N4 soeve- /e5,a
Parent Material (gejlcgic) .-rerr. L,..Ygsr.../_x.TCke t3.yl.
Oeot- to Groundwete,:
Standing Wa pr in the lio(e:/✓OtiE
Depth to Bedrock: 9D
r
Weeping from Pit Face:KO• '&-
:;i nate Seasonai tilyn Ground Water: /!tp
FORM 11 • SOIL EVALUATOR FORAM
Page 2 of 3
Location Address or Lot No. 3 $O c»s re z F/t[rle (79
-T On-site Review
Deep Hole Number y_. Date:.M.:e?:9' Time:.2ro°f-%'7 Weather $uwuX .
Location (identify on site plan) _.. ....._... . ..__. _
Land Use ./i'
�����fi-o-u.Ti4L Slope (%) S Surface Stones Ft/a.ei.c -
Vegetation &..Ir' Al. ,._.... ....
Landform .."j-.cJtRO
Position on landscape (sketch on the back) ,
Distances from: �
Open Water Body <0410 feet Drainage way poe "feet
Possible Wet Areaa/Ot . feet Property Line.°v 2Or feet
Drinking Water Well /00*/ feet Other
DEEP OBSERVATION HOLE LOG.
Depth from
Surface(Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
IMunselll
Soil
Mottling
Other
(Structure,Stones. Boulders,Consistency, %
Gravel)
S to lye"
A
FI
C
L�S
1pye)12
/bye�J
ND
jots 4i
5arr
?•5y1)74,
d•Sya
b.xy 4 At s
s Ln ST
/47 Ce1,CC, A+ •*>
To p,r)
41aNEe
/Cc!4.4.1? 6rt+eId°9r,Fc> 9,-o>
/to✓�r fl-*Le/ o gD 4140EL
MINIMUM OF 2 HOLt3 RoQUU ED—A-7 VERY PSQPOScD DISPOSAL AR
Parent Material(geelogic) LcE ea..idee) tM74,A9 L.
Depth to Groundwater: Standing Water in the Hole:
Estimated Seasonal High Ground Water:
•
DepdnoBedrock: l 06
Al nut Weeping from Pit Face: /Via Arc
saes
DEP APPROVED FORK-'22/07/95
Location Address or Lot No.
FORM 11 - SOIL EVALUATOR FORM
Page 2 or 3
3 80 CW E sT&2 F F(& !WW
On-site Review
Deep Hole Number ,y . Date: /0:),:f
Location (identify on site plan)
Land Use EC.�././5s!!!_7-44, Slope (%)
Vegetation 49h1 4. . ._.
Landfcrm 1-'Lfc&n ct __..
Position on landscape (sketch on the back)
Distances from:
Open Water Body /era feet
Possible Wet Areaa.# - feet
Drinking Water Well lee*" feet
Time:.2/o o fir?
Weather St.A-.
S Surface Stones .Vd_et.c . . _
Drainage way
6o' feet
Property Line&O'w 2t' feet
Other
DEEP OBSERVATION HOLE LOG'
Depth from
Surface(Inches)
p to Gr'
b Zo Sa
52 to fob'
Soil Ho
on Soil Texture Soli Color Sail
(USDA) (Munsell) Mottling
(Pye 3j
ND
Other
(Structure.Stones. Boulders, Consistency, %
Gravel)
bsvireei f La.a.,
,af0%e H! /L/ ! Co33r!e-s Yr..� 412..+E
5.1 "
,'aye.3/
asy,s
To zoo
I M1l4-Yii/ M/ cogo It/ 9M/1
ThiltLer ao ?o G+a&AEC
MINIMUM OF 2 hOLca H-CuIMtD AT c cJ�'riy Pr OPOpcD DISPOSAL An A
DepthtaBedrock: /0 ro
Parent Material(geologic) —Lc? ro—>ae> Or/rjr.A9 S
Depth to Groundwater Standing Water In the Hole:
Estimated Seasonal High Ground Water: 52 "
'r
Nb
r/
Weeping from Pit Face: /Ver It.-6-
DEP APPROVED FOR51-10/07/95
No.
FORM 11 - SOIL EVALUATOR FORM
Page 1 or 3
Date: 102__
Commonwealth of Massachusetts
NoiAto.4.,(2-12,..0, Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By: lEA.2.6,..1.2 a- LAS et> E7
Witnessed By: ..amt-e, m
Date: zo-c,
Lzet—mdt— 12D em' L'Er Pc:4"—/ 462 &a
La I
No-ez N4 ..)7/711-7'
New Construction I: Repair E.
0-, -nit.. 5 6AteZice D. Di Cr/Cki.50 A-1
TciccIm/
• 3 b D cz..ire:Qn /42 R.,2
. e Ats
Office Review
Published Soil Survey Available: No El Yes
■
Year Published .121.12.C.L. Publication Scale f:/.57.(sli.G.1 Soil Map Unit 13 C
Drainage Class naish ,•etriv Soil Limitations 31-api...5.
a...,„D
Surficial Geologic Report Available: No E Yes El ?opt CE et-a-ea- TE)
Year Published
Geologic Material (Map Unit)
Landforn .1E..••••••
Publication Scale
Flood Insurance Rate Map:
Above 500 year flood boundary No
Within 500 year flood boundary No
Within 100 year flood boundary No
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
0 Yes El
0
75-Yes
SYes
Current Water Resource Conditions (USGS): Month
Ranee :Above Normal ONormal Below Normal 0
Other References Reviewed:
• wit e--le ‘ •-ert•l"
C
DEP APPROVED FORM-I 2/07/95